This
study found that 'condom serosorting' – being open to sex with serodiscordant
partners, but always using condoms with them – was far less popular as a
strategy, as was ‘seropositioning’ – being top (insertive) when you are negative, bottom (receptive) if
you are positive.

The
Seattle study did not report on ‘viral sorting’ – having unprotected sex with
men with HIV if they have an undetectable viral load – but a study from Germany
found that 10% of men with HIV there regarded themselves as non-infectious if
they had an undetectable viral load and based their choices about sex on this belief.

It found
that men who used viral sorting were far less likely to disclose their status
or talk about HIV. The Seattle researchers are collecting data on viral load and will report on this soon.

Serosorting in Seattle

The
Seattle study was designed to find out whether the sexual risk behaviour
patterns men disclosed in a typical behaviour survey were purposeful – that is, whether they were part of a considered HIV
risk strategy. Between February and August 2013, researchers at the Seattle
HIV/STI clinic asked gay male service users to fill in two separate questionnaires:
one detailing their actual recent sexual risk behaviour (condom use, status of
partners, sex role and so on) and the other asking them what sexual risk
strategies they tried purposefully to use. Eligible men was anyone who was at least 18 years old, who who reported any sex with a man in the past year, and who
spoke English.

Out
of 1902 eligible men, 51% (964) completed both questionnaires, of whom 835
(87%) were HIV negative and 129 (13%) were HIV positive. The questionnaire
asking about chosen strategy asked specifically whether they used one of these
three strategies:

Strict serosorting, i.e. only having sex, with or
without condoms, with partners of the same HIV status;

Condom serosorting, i.e. only having condomless sex with partners of the same
status, but allowing sex with condoms with partners of opposite or unknown
status;

Seropositioning, i.e. having condomless sex with
partners of any HIV status but being the insertive partner (‘top’ if
HIV negative or the receptive partner (‘bottom’) if HIV positive.

Fifty-five
per cent of the men (both HIV positive and negative) reported some kind of
seroadaptive behaviour, meaning that their choice of partner or behaviour was
correlated in some way with their partner’s HIV status. Fifty per cent of HIV-negative men and 42% of HIV-positive men (46% on average) reported in the other questionnaire
that this was part of a deliberate strategy. This means that 86% of men who showed
seroadaptive behaviour agreed they were using it as part of a conscious strategy.

Strict
serosorting was by far the most popular strategy of the three options listed by
the researchers. The respective figures for those who were strict serosorters,
condom serosorters, or 'seropositioners' were 42% of HIV-negative respondents for strict serosorting (with 39%
saying it was their chosen strategy), 6.5% for condom serosorters (5.2% saying
it was their strategy), and 7.1% using seropositioning (with 6.5% saying it was
their chosen strategy).

Strict
serosorting was less popular with HIV-positive men, with 32% doing it as behaviour and 25% as strategy, while the other two
behaviours were more popular than in HIV-negative men, at 11% for condom serosorting and 10% for seropositioning.

This
means that for 42% of HIV-negative and 33% of HIV-positive men, their main
strategy for keeping themselves safe was to to restrict sex to people they knew or presumed to be of the same HIV status, or avoid sex with people who they knew to be of
the opposite HIV status. This strategy was systematic and
planned by 39% and 26% of them respectively. Strict serosorting was practised
by 75% of HIV-negative men and 60% of HIV-positive men who had any
sero-adaptive behaviour.

”Serosorting
is overwhelmingly the most common seroadaptive behavior in our clinic,” comment
the researchers.

Viral load in Germany

One
strategy not considered by the researchers was ‘viral sorting’ – men basing condom
use decisions with HIV-positive partners on whether or not they have a
detectable viral load. At the conference, the interim results of the PARTNER
study, which found no transmissions from anyone with HIV who had a viral load
below 200 copies/ml, were big news.

A
qualitative German study that asked 269 HIV-positive gay men whether they
regarded themselves as uninfectious when they had an undetectable viral load found that 10%
of HIV-positive men said they took this into consideration.

The
researchers found considerable differences in condom use, STI risk and
disclosure between men who adopted a 'viral sorting' strategy and other men
with HIV. They found that 57.5% of viral sorters had had recent condomless sex
compared with 36% of those who had not and that they were much more likely to
say that they had had anonymous casual sex (70% versus 44%).

While
these behaviours might not risk HIV transmission by people who really do have an undetectable viral load, they do
lay them open to transmitting and acquiring other STIs. The researchers were also concerned that the
adoption of a 'viral sorting strategy' seemed to involve discussing and
disclosing HIV status much less. Only 19% of 'viral sorters' said they had
recently disclosed their HIV status versus 42% of others, and only 22% said
they had discussed the topic of HIV at all, versus 44% of others.

This
study can’t determine whether gay men living with HIV are using their viral load
knowledge to reassure themselves that they do not have to discuss their status
with partners, or are using it as a post-hoc rationalisation for not having
disclosed.

Either way, they suggest that when the original "Swiss statement"
was published in 2008, it was assumed that viral load would be discussed as part of
HIV status disclosure between partners, rather than being used as a substitute for discussion.

"Without
open serocommunication in these settings, other – potentially asymptomatic – STIs
may be passed on,” the researchers comment. “Thus, a subversion of a basic
condition of viral load sorting seems possible.”

Given,
however, what the Seattle study reveals – that HIV-positive men may meet with a
flat rejection of sex by over 40% of HIV-negative prospective partners if they
do disclose – it is perhaps understandable if some HIV-positive men regard "undetectable equals uninfectious" as primarily excusing them of an obligation
to disclose.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.

The Community Consensus Statement is a joint initiative of AVAC, EATG, MSMGF, GNP+, HIV i-Base, the International HIV/AIDS Alliance, ITPC and NAM/aidsmap

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This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends
checking whether this is the most current information when making decisions that may affect your health.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member
of your healthcare team for advice tailored to your situation.